Exam 1

Complete Health History (Subjective Data)

Biographic Data

• Name, address, age, gender, race, occupation, etc.

Reason for Seeking Care

• Not a diagnostic statement

Source of History

• Judge reliability of informant

Present Health or History of Present Illness (HPI)

• Collect all provided data and identify eight critical characteristics

  • Location, character (quality), quantity (severity), timing, setting, aggravating or reliving factors, associated factors and patient’s perception

• Use measurable standards and/or patient’s own wards as qualifiers

Critical Characteristics

• Location

• Character or quality

• Quantity or Severity

• Timing— onset duration, and frequency

• Setting

• Aggravating or relieving factors

• Associated factors

• Patient’s perception

Past Medical History*

Family History

Review of Systems (ROS)

• Evaluate past and present state of each body system

• Notes on body system

• Evaluate health promotion practices

• Record either presence or absence of symptoms (no writing negative)

• NO OBJECTIVE data

• Focus on health promotion

Functional Assessment

• OBJECTIVE measures

Mental Status— Level of Consciousness

• Alert

• Lethargic- Drifts off to sleep when not stimulated

• Obtunded- Sleep most of the time, difficult to arouse

• Stupor/Semi-coma— unconscious; responded to persistent vigorous shake or pain

• Coma

• Delirium

General Survey (Objective Data)

• Study of the whole person

Physical Appearance

• Age: What age they look like or stated age

• Sex

• Level of consciousness

• Skin color

• Facial features

• Overall appearance

• Stature

• Nutrition

• Symmetry

• Posture

• Position

• Gait

Behavior

• Facial expression

• Mood and affect

• Speech

• Dress

• Personal hygiene

• Height

  • Shoeless

• BMI

  • Can indicate protein-calorie malnutrition

Malnutrition

• Marasmus - Protein-calorie malnutrition

  • Decreased anthropometric measurements (i.e. weight loss and subcutaneous fat and muscle wasting

• Anorexia, bowel obstruction, cancer cachexia

Waist Circumference

• Assess body fat distribution as indicator of health risk

• Excess abdominal fat is an independent risk factor for disease, over and above that of BMI

• Note measurement at end of normal expiration

• Android (upper body obesity):

  • 1.0 or greater in men or 0.8 or greater in women

  • Risk for obesity-related diseases and early mortality

Metabolic Syndrome

Three or more of the following risk factors are present

1. Fasting plasma glucose level greater than or equal to 100 mg/dl blood pressure greater than or equal to 100 mg/dl

2. blood pressure greater than or equal to 130/85mm hg

3. waist circumference greater than or equal to 40 inches for men and 35 inches for women

4. HDL cholesterol less than 40 in men and less than 50 in women (high- density lipoproteins- “Good)

5. triglyceride levels greater than or equal to 150 mg/dl

Nutrition Assessment: Subjective Data

• Eating patterns

• Usual weight

• Changes in appetite, tase, smell, chewing, and swallowing

• 24hr dietary recall for average day (type, amounts, liquids)

Different Types of Pain (Can originate from the PNS/CNS)

1. Acute

2. Chronic

3. Nociceptive (ex: pain from pinching)

4. Neuropathic (ex: phantom pain)

Assessment of Pain

• Distinguishing sensations

• Different responses to analgesics

• Structural Plasticity / Reorganization of Pain Pathways: result from long-term uncontrolled pain — cells altered in size and function in dorsal horn

  • associated with nociceptive hypersensitivity

• Nociception four phases

  • Transduction— Chemicals release

  • Transmission— Chemical reach CNS and move from spinal cord to brain

  • Perception— Pain perception

  • Modulation— Brainstem neurons block pain impulse

Sources of Pain

• Referred- Originated at one site but is felt at another (ex: Acute coronary syndrome radiates to left arm or neck

• Visceral- “Think visceral organs”

  • dull, deep, squeezing, craming

  • ANS associated vomiting, nausea, pallor, and diaphoresis

• Somatic- musculoskeletal tissues or body surface

  • localized / easy to pinpoint

  • Deep somatic- blood vessels, joints, tendons, muscles and bone-aching/throbbing

• Cutaneous- integumentary/subcutaneous

• Breakthrough pain- transient spike in pain level with moderate to severe intensity in an otherwise controlled pain syndrome from…

  • End of dose medication failure

  • Result of incident or episodic pain

Pain Assessment / Subjective Date and Tools

• Initial Pain Assessment

• Onset

• Intensity

• Quality

• Duration

• Frequency

• Location

• Aggravating factors

• Relieving factors

Skin

Skin Function (besides the obvious)

• Temp reg

• Identification

Skin Layers

• Epidermis— Basal cell layer forms new skin cells; replaced every 4 weeks

  • Melanocyte related to melanin

• Dermis— Supportive layer consisting of CT or collagen

• Subcu— composed of adipose, energy, insulation for temp control, protective soft cushioning effect, mobility over structures underneath

Skin / Hair / Nails

• Vellus— fin faint hair covers most of body

• Terminal hair— thicker, darker, scalp

  • Can exist in face / chest in males

• Sebaceous (oil) glands— abundant on scalp, forehead, face, and chin

• Sweat glands

  • Eccrine— sweat

  • Apocrine— open into hair follicles, thick milky secretion, bacteria creates musky body odor

• Nails— made of keratin

Physical Examination of Hair and Nails

• Separate intertriginous areas (areas with skinfolds) such as under large breasts, obese abdomen, and groin, and inspect them thoroughly

• Assess skin as one entity

Summary Checklist

• Inspection of the skin, hair, and nails

  • Includes shape, contour, and consistency

• Palpation of skin, hair, and nails

  • Temp and texture

  • Edema, mobility, and turgor

• Note presence of lesions

  • Includes configuration / Distribution

Inspection / Palpation of Hair

• Color

• Texture

• Distribution

• Lesions

Inspection / Palpation of Skin

• Color

• Temperature

  • Take into account the temp of the environment

• Moisture

  • Includes diaphoresis

• Texture

• Thickness (look for calluses)

• Edema

• Mobility / Turgor

• Vascularity / Bruising

• Erythema - intense redness of the skin due to excess blood in dilated superficial capillaries, as in fever or inflammation

• Carotenemia - yellow pigmentation of the skin (palm, soles and nasolabial fold secondary to excretion by sebaceous glands in sweat) associated with increased blood carotene (Vit A) levels (carrots, squash, pumpkin, breast milk)

  • Jaundice due to excess bilirubin (includes yellow sclera)

Skin Lesions

1. Color

2. Elevation: flat, raised, or pedunculated

3. Pattern or Shape: the grouping or distinctness of each lesion

4. Size in centimeters: use a ruler

5. Location and distribution: generalized or localized to area of specific irritant

6. Exudate: color and odor

Inspection / Palpation: Nails

• Shape and contour

  • View index finger at its profile and note angle of nail base; it should be about 160 degrees

• Consistency

  • Observe for smooth, regular, not brittle or splitting, uniform nail thickness

• Color    

  • Transulecent nail plate to pink nail bed below

  • Note ethnic variations

• Capillary refill

  • index or middle finger at heart level

  • depress for at least 5 sec

• Clubbing

  • nail bed straightens to 180 degrees

  • pulmonary disease

ABCDEF Skin Assessment

• A: asymmetry

• B: border irregularity

• C: color variations

• D: diameter greater than 6 mm

• E: elevation or evolution

• F: funny looking

Shapes / Configuration of Lesions

• Confluent

  • Lesions run together (ex: hives)

• Discrete

  • Distinct and separate

• Grouped

  • Cluster (ex: eczema)

• Linear

  • Scratch, streak, line, or stripe

• Zosteriform

  • Follow unilateral nerve route (ex: herpes zoster)

Primary Skin Lesions

• Tumors

  • Large in diameter, firm or soft, deeper into dermis, may be benign or malignant

• Urticaria (hives)

  • Wheals (superficial, raised, transient, erythematous, slightly irregular from

    edema (mosquito bite, allergic reaction) coalesce to form extensive

    pruritic reaction.

• Vesicles

  • Elevated (up to 1 cm)

  • Containing fluid (clear serum)

  • i.e. herpes; blister

• Cysts

  • Encapsulated fluid filled cavity (bigger than vesicles)

• Pustules

• Macule

  • Just a color change

  • Flat and circumscribed (less than 1 cm)

  • ex: Freckle

• Papule

  • Solid, elevated, circumscribed less than 1 cm diameter

  • Mole or wart

Secondary Skin Lesions

• Debris

  • Crust— Thickened dried out exudate

  • Scale— Compact flakes (shedding)

• Break

  • Fissures— Linear crack with abrupt edges extending into dermis (“look like cracks)

  • Erosions— Shallow depression (scooped out)

  • Ulcers— Deeper depression extending into dermis with irregular shape, may bleed, leaves scar

  • Excoriations— Self-inflicted abrasion that is superficial

  • Atrophic scars— Depressed scars

  • Lichenifications— From intense scratching → thickened skin → tightly packed papules

  • Keloids— Benign excess of scar tissue beyond original injury

Pressure Injuries (PI)

• Pressure ulcer

• Decubitus ulcer

• Deep depression extending into dermis

Stages

1. Non-blanchable erytheme

2. Partial-thickness skin loss

3. Full-thickness skin loss

4. Full-thickness skin/tissue loss

Vascular Lesions

• Caused by blood flowing out of breaks in the vessels

• Petechiae: tiny punctate hemorrhages indicating

  abnormal clotting factors (check mouth, buccal mucosa,

  conjunctivae)

• Purpura: > 3mm, flat, red to purple macular hemorrhage

  seen with thrombocytopenia and old age as blood leaks

  from capillaries in response to minor trauma

• Contusion: (Bruise) red-blue or purple immediately then

  blue-green, yellow and brown from trauma

Non Cancerous Findings

• Seborrheic Keratosis: dark, greasy and “stuck on” Develop

  mostly on trunk, hands and face on both unexposed and sun

  exposed areas. Do not become cancerous.

• Actinic keratosis: red-tan scaly plaques, raised roughened.

  May have silvery white scale adherent to plaque. Occurs on

  sun-exposed surfaces and are directly related to sun

  exposure. Premalignant and may develop into squamous

  cell carcinoma.

• Senile lentigines (lenltigo): common variation of

  hyperpigmentation, liver spots, flat brown macules, extensive

  sun exposure and are not malignant and do not require

  treatment.

Malignant Skin lesions (From UV Sunlight / Tanning Bed Radiation)

• Basal Cell Carcinoma: small pink or red papule with pearly

  translucent top and broken blood vessel at center then

  develops rounded, pearly boarders with central red ulcer or

  large open pore with central yellowing- slow growing

• Squamous Cell Carcinoma: arises from actinic keratoses or

  denovo. Erythematous scaly patch with sharp margins, 1 cm

  or more, develops central ulcer and surrounding erythema-

  fast growing

• Malignant Melanoma: Brown, tan, black, pink-read, purple or

  mixed pigmentation. Irregular boarders, scaling, flaking ,

  oozing

Wounds:

• Abrasion: scrapes from friction on rough surface

• Incision: clean cut from sharp object (ex: scalpel)

• Laceration: irregular tear

• Puncture

• Avulsion: characterized by flap

Assess:

1. approximation of edges

2. color,

3. edema,

4. drainage

5. exudate

6. odor

7. Pain

Thorax and Lungs

Anterior Thoracic Landmarks

• Suprasternal notch: U-shaped in between clavicles

• Sternum: “breastbone” / manubrium

• Manubriosternal angle: Angle of Louis; Crack

  • Angle of Louis marks site of tracheal bifurcation into right and left main bronchi

• Costal Angle: right and left costal margins form an angle (^)

Lobes of the Lung

• Posterior Chest: almost all lower lobes

• Lateral chest: lung tissue goes from apex of axilla down to seventh / eighth rib

• Left lung: no middle lobe / very little lower lobe (mostly upper and middle)

Thorax and Lungs Examination

• Inspection

  • Thoracic cage, respirations, skin color, and condition

• Palpation

  • Symmetry and tactile fremitus (“99" / “Blue moon”)

  • Detection of any lumps, masses, or tenderness

• Percussion

  • Resonance

  • Assess breath sounds (presence/quality), normal and note any abnormal/adventitious sounds

Inspection of Anterior Chest

• Shape/configuration of chest wall

• Note respiratory effort

Palpation of Anterior Chest

• Tactile Fremitus (“99”)

  • Decreased fremitus with pneumothorax

  • Increased fremitus with severe pneumonia

• Note tenderness/lumps

• Note skin mobility, turgor, temp, and moisture

• Hyperinflation of lungs = chronic emphysema and asthma

Percussion of Anterior Chest

• Bilateral comparison

• Do not percuss directly over female breast; displace breast

• Borders of cardiac dullness normally found on anterior chest

  • Right hemithorax = liver dullness located in fifth intercostal space, right midclavicular line

  • Left hemithorax = over gastric space

• Resonance is normal lung sound in all fields

Breath Sounds

• Three types of breath sounds heard normally in adults and older child

  • Bronchial- trachea and larynx

  • Bronchovesicular- over major bronchi

  • Vesicular: over peripheral lung fields, bronchioles and alveoli

• Note description of characteristics

Auscultation Breath Sounds

• Crackels (Rales)

  • Fine

    • Popping (Inspiration)

    • Obstructive disease

    • Chronic bronchitis, emphysema, NOT cleared by coughing

  • Coarse

    • Velcro (Inspiration / Expiration)

    • Pulmonary edema, pneumonia, terminally ill with depressed cough reflex

    • Reduced by coughing

• Wheezes (Ronchi)

  • High pitched sibilant

    • Squeaking, musically (Expiration, Inspiration secondary)

    • Acute asthma or chronic emphysema

  • Low Pitched

    • Snoring (cleared somewhat with coughing)

    • Airflow obstruction, bronchitis, bronchus obstruction

Stridor Sound: Rooster

• Upper air way obstructions or swelling, croup or foreign body inhalation

Posterior Chest

• Inspection

  • Shape and configuration of chest wall

  • Position the person take to breathe

  • Lesions; inquire about changes

• Palpation

  • Symmetric

  • Tactile fremitus (“99” or “blue moon”)

• Percussion

  • Resonance is low-pitched, clear, hollow sound that predominates in healthy lung tissue in adult

• Auscultation

Tactile Fremitus

• Increased:

  • Occurs with conditions that increase lung tissue density (better conduction medium for vibrations)

  • Pneumonia

• Decreased:

  • Obstructs transmission of vibrations

  • Obstructed bronchus, pleural effusion, thickening pneumothorax, emphysema

Voice Sounds Auscultation

• Normal voice transmission is soft, muffled, and indistinct

• Increased lung density / transmission of voice sounds = Disease

Respiratory Patterns

• Tachypnea- >24 per min; fever, fear, exercise, pneumonia, and respiratory insufficiency

• Bradypenea- <10 per min; drug-induced depression or increasd intracranial pressure and diabetic coma

• Chronic Obstructive breathing- normal inspiration and prolonged expiration; chronic obstructive lung disease

• Cheyne-Stokes Respiration: cycle respirations gradual wax and wane in pattern with increasing rate and depth and then decreasing

  • Periods of apnea

  • Severe heart failure

  • Drug overdose

  • Increased intracranial pressure

  • May be normal for infants / older adults

Abdomen

Internal Anatomy

• Peritoneum lines abdominal wall (parietal)

• Covers surface (visceral) of most organs

• Divided into 4 quadrants

Anatomic Locations of Organs in the Right Upper Quadrants

• Liver

• Gallbladder

Left Upper Quadrant

• Stomach

• Spleen

• Left lobe of liver

Right Lower Quadrant

• Appendix

• Right Ovary Tube

Culture and Genetics

• Lactose Intolerance

  • Lack of lactase

  • Estimated incidence of lactose intolerance is

    • 20% and 30% of whites, 70% of Mexican Americans, and 80% of blacks and 100% American Indians

• Celiac Disease (autoimmune disorder)

  • Intolerant of gluten roughly 1% of 4$ with a diagnosis-most affect Punjab region of India

Subjective Data

• Appetite

• Dysphagia

• Food Intolerance

• Abdominal Pain

• Nausea and Vomiting

• Bowel habits

• Past abdominal history

• Medications

• Nutritional assessment

Development Competence: Aging

• Changes of GI system occur with aging, but most do not significantly affect function as long as no disease is present

  • Salivation decreases = dry mouth / lack of taste

  • Esophageal emptying and gastric acid secretion are delayed

• Incidence of gallstones in creases with age

• Drug metabolism impaired

Abdomen Examination (Summary)

• Inspection

  • Contour, symmetry, umbilicus, skin, pulsation or movement, hair distribution, and demeanor

• Auscultation

  • Bowel wounds; note any vascular sounds

• Palpation

  • Light and deep palpation in all four quadrants (for liver and spleen)

Objective Data

• Position for comfort to enhance abdominal wall relaxation

  • Examine painful areas last to prevent guarding

• Auscultate prior to palpation

• Use distraction to keep patient relaxed and facilitate muscle relaxation

Inspection of the Abdomen

• Contour

  • Determine profile from rib margin to pubic bone; contour describes nutritional state and normally ranges from flat to rounded

• Symmetry

  • Abdomen should be symmetric bilaterally

• Umbilicus

  • Normal it is midline and inverted, with no sign of discoloration, inflammation, or hernia

• Skin

  • Inspect for pigment change and presence of lesions or scars

• Pulsation or Movement

  • Normally, may see pulsations for aorta beneath skin in epigastric area, particularly in thin persons with good muscle wall relaxation

• Demeanor

Auscultation

• Don’t push stethoscope too hard against body

• Auscultate for bruits (swishing during systole) over aorta

  • Look both renal arteries and iliac arteries

Bowel Sounds

• Character and frequency

• Happen 5-30 times/min

• Abnormal

  • Hypoactive— from abdominal surgery or with inflammation

  • Hyperactive— increased motility

    • Borborgymus from bowel obstruction, gastroenteritis, brisk diarrhea

• Listen for 5 minutes before saying bowels sounds are completely absent

Vascular Sounds

• User firmer pressures over arteries (especially with people with hypertension)

Light and Deep Palpation

• Mild tenderness normally present when palpating sigmoid colon

• When identifying a mass, distinguish it from a normally palpable structure or enlarged organ

Noting Mass

• Location

• Size

• Shape

• Consistency: soft, firm, hard

• Surface: smooth, nodular

• Mobility, including movement with respirations

• Pulsatility

• Tenderness

Palpation of Spleen and Liver

• Spleen must be enlarged three time it normal size to be felt

• Deep palpation might feel lower edge of liver

Palpation of Aorta

• Using your opposing thumb and fingers, palpate aortic pulsation in upper abdomen slightly to left of midline

• Pulsates in an anterior direction

• Widened in the present of abdominal aortic aneurysm (anormal bulge or ballooning of blood vessel wall)

Aging Adult

• May not increased deposits of subcu fat on abdomen and hips because it is redistributed away from extremities

• Liver and kidneys easier to palpate

  • With distended lungs and depressed diaphragm, liver can be palpated lower, descending 1 to 2 cm below costal margin

Costovertebral Angle Tenderness (CVAT)

• Positive finding of pain indicates inflammation of the kidney

Urine

• Slightly acidic (pH 4.5 - 8.0)

• Cloudiness suggests presence of WBC, bacteria, and casts

Daily Fluid Intake

• About 15.5 cupts (3.7 L) for men

• About 11.5 cups (2/7 L) for women

• Water 8-8oz. glasses

Bowl Movement and Stool Characteristics

• Usual Elimination pattern (number of stools daily, time of day, routine)

   Color

   Shape

   Consistency (hard, soft)

   Changes???

   Appetite and nutritional intake (fruits, veggies, roughage)

   Fluid intake

   Medications

   Exercise

   Living arrangements

   Mobility and dexterity

• Note:

   Abdominal Distention

   Feces palpable in Descending colon

   Pain

   Abnormal Bowel sounds (hyper, hypo)

   Consider constipation, impaction, diarrhea, incontinence, flatulence,

  hemorrhoids

Heart and Neck Vessels

Position and Surface Landmarks

• Precordium: area on anterior chest overlying the heart and great vessels

• Superior and Inferior Vena Cava return unoxygenated venous blood

• Pulmonary Artery → (Unoxygenated to) Lungs

• Pulmonary Veins → (Oxygenated to) Heart

• Pulmonary vs Systemic Circulation

• Pericardium - Protects

• Myocardium - Muscle

• Endocardium - Lines inner surface

Heart Chambers

• Four chambers separated by valves (prevent backflow)

• Four valves

  • Two atrioventricular (AV) valves - Separate atria and ventricles

  • Two semilunar (SL) valves

AV Valves

• “Tri(cuspid) before you (bi)cuspid”

  • Chordae tendineae anchor

SL Valves

• No valves are present between vena cava (great vessel putting blood into pulmonary side of heart) and right atrium, or between pulmonary veins (into systemic side) and left atrium

  • High pressure, left side heart = pulmonary congestion

  • High pressure, right side heart = shows in neck veins and abdomen

Cardiac Cycle

• Diastole: 2/3 of cardiac cycle;

  • Pressure in the atria is higher than ventricles;

  • Toward the end of diastole, atria contract and push last mount of blood (25% of stroke volume) into ventricles (called presystole / atrial systole / atrial kick)

  • Atrial systole occurs during ventricualr diastole

• Systole 1/3 of cardiac cycle

  • AV valve closure contribute to S₁ (signals beginning of systole)

• For a brief moment all four valves are closed and ventricular walls undergo:

  • Isometric Contraction (First Stage of Systole):

    • PART OF SYSTOLE THAT AMPS UP VENTRICULAR PRESSURE TO PREPARE TO SHOOT OUT INTO PULMONARY / SYSTEMIC ARTERY

    • Contraction against closed system works to build high level pressure in ventricles

    • Left side heart, when the pressure exceeds the pressure in aorta, the aortic valve opens and blood is ejected rapidly

    • Pressure falls after ventricles empty

    • When pressure falls below pressure in the aorta, some blood flows backward toward the ventricle causing the aortic valve to swing shut

  • Closure of the SL valves causes S₂ (signals end of systole)

• Diastole Again

  • Isometric contraction

    • Four valves closed and ventricles relax

    • Relaxation of the ventricles (decrease pressure lower than the atria) to allow blood to move into the ventricles (from the atria)

• Same events occur on both sides of heart

  • Right side requires lower pressure and sequence occurs slightly later

Characteristics of Heart Sounds

• Frequency

• Intensity— loud or soft

• Duration— very short for heart sounds; silent periods are longer

• Timing— Systole or diastole

Extra Heart Sounds

• S₃

  • Ventricles resistant to filling during protodiastole

  • Immediately after S₂

  • Normal in athletes; indicates congestive HF in people >35 years)

• S₄

  • During presystole

  • Caused by vibration of ventricular wall during atrial contraction

  • Associated with stiffened ventricle (low ventricular compliance)

  • Hear in patients with ventricular hypertrophy, myocardial ischemia, or in older adults

Murmurs

• Create turbulent blood flow

• Conditions resulting in murmurs

  • Velocity of blood increases

  • Viscosity of blood decreases

  • Structural defects in valves

• 6-point (severity) scale

  • Grade 1: Easy to miss

  • Grade 2: Quiet by noticeable

  • Grade 3: Moderately loud

  • Grade 4, 5, and 6…

Conduction

• Specialized cells in sinoatrial (SA) node initiate electrical impulse

  • SA Node = pacemaker

Pumping Ability

• 4-6 L of blood per min (resting)

• CO = HR x SV (vol of blood pumped from left ventricle per beat)

Neck Vessels

• Carotid artery timing coincides with ventricular systole

• Jugular Venous Pulse empties unoxygenated blood into superior vena cava

  • No valve between vena cava and right atrium

    • jugular veins give info about activity on right side of heart

  • Volume and pressure increase when right side of heart fails to pump efficiently

Developmental Competence

• Pregnant women = More blood vol and CO / decrease blood pressure

Hemodynamic Changes with Aging

• Isolated Systolic HTN: increase in systolic BP due to thickening/stiffening of arteries

  • Ability of heart to augment CO with exercise is decreased

• Dysrhythmias

  • Presence increases with age (ectopic beats common = may compromise CO and BP when disease present)

  • Tachyarrhythmias may not be tolerated as well in older people

Culture and Genetics

• Cardio Vascular Disease (CVD): most common underlying cause of death globally

• Risk Factors

  • HTN

  • Smoking

  • Serum Cholesterol (Low HDL, HIGH LDL)

  • Inactivity

  • Sex and gender

• Nocturia associated with CVD

• Assess jugular veins and precordium while patient is supine (head and chest slightly elevated)

Neck Vessel: Inspection

• Jugular Vein Pulse

  • Assess central venous pressure (judges heart’s efficiency as a pump)

  • Semi-fowler’s position

  • Observe for distention

• Characteristics of jugular versus carotid pulsations

  • Differentiate between:

    • Location

    • Quality

    • Respiration

    • Palpable

    • Pressure

    • Position of pt

Neck Vessel: Palpation and Auscultation

• Palpate carotid

  • Feel contour and amplitude of pulse (2+)

• Auscultate carotid

  • Carotid bruit— blowing, swishing sound from blood flow turbulence (use bell, ask patient to take a breath, exhale and hold it briefly while you listen)

  • Carotid bruit is audible when lumen is occluded by ½ to 2/3 (full occlusion = bruit disappears)

Abnormal Pulsations: Precordium

• Thrill = incompetent heart valve

  • Feels like the throat of a purring cat

• Lift (heave) at the sternal border

  • Can be palpated

  • Indicates right ventricular hypertrophy

Precordium Auscultation

• Valve areas are not the anatomic location of the valves but the sites on the chest wall where sounds produced by the valves are best heard

• Note rate and rhythm

• S₁ and S₂

• Listen for murmurs

• Listen for extra heart sounds

Heart Failure

• Decreased CO when heart fails as a pump, causing back up

• Signs and symptoms

  1. Heart inability to pump enough blood to meet metabolic demands

  2. Abnormal retention of sodium and water (from kidney) to compensate for decreased CO

     • Increases blood volume and venous return, causing further congestion

Structure and Function of Arteries

• Arteries stretch with systole and recoil with diastole

• Vascular smooth muscle = Vasodilation/constriction

Structure and Function: Arteries

• Accessible Pulses

  • Temporal

  • carotid

  • brachial

  • ulnar

  • popliteal

  • dorsalis pedis

  • posterior tibial

• Peripheral Arterial disease (PAD) affects noncoronary vessels and refers to arteries affecting limbs

• Grading the force

  • 0 = Absent

  • +1 = Weak

  • +2

  • +3 = Bounding, hyperthyroidism, etc.

Structure and Function: Veins

• Capacitance vessels

• Venous stasis (error in contracting musculoskeletal system and patent lumen)

  • Risk Factors:

    • Prolonged standing, sitting, or bed rest (non contracting muscles)

    • Hypercoagulable states (clots)

    • Dilated varicose veins = incompetent valves = backflow = increase venous pressure = dilates the vein

    • Risks: genetic predisposition, obesity, and multiple pregnancies

Structure and Function: Venous Flow

• Mechanism to keep blood moving

  • Contracting skeletal muscles

  • Pressure gradient from breathing

  • Intraluminal valves ensure unidirectional flow

  • Calf pump / peripheral heart

• Abnormalities

  • Varicose veins— dilates and tortuous create incompetent valves → venous pressure → further dilation

  • DVT— more than 2cm asymmetry, redness and pain

  • Pitting Edema— bilateral, heart failure, diabetic neuropathy, hepatic cirrhosis

    • +1 Mild, slight indentation, no perceptible sweeling of leg

    • +2 Moderate, indentation subsides rapidly

    • +3 Deep pitting, indentation remains for a short time, leg looks swollen

    • +4 Very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted

Structure and Function: Lymphatics

• Retrieve excess fluid and plasma proteins

• Arteriole hydrostatic pressure leaks out fluid out of the capillaries (more than the venules can absorb)

• Colloid osmotic pressure pulls interstitial fluid back into the venules (from plasma proteins being too big to be pushed out of the arterioles, resulting in a force that creates this pressure)

• Functions

  • Vacuum up interstitial fluid

  • Immune system

  • Absorb lipids

Spleen Functions

• Destroy old RBCs

• Produce antibodies

• Store RBCs

• Filter microbes from blood

Tonsils

• Palatine, adenoid, lingual

Aging Adult

• Develop arteriosclerosis → more prevalence of PAD

• Assess for increased risk for acute DVT and all the risks

• Loss of lymphatic tissue leads to fewer numbers of lymph nodes and to decrease in size of remaining nodes

Culture and Genetics

• PAD risk for CAD

• Environmental factors: Smoking, diabetes, HTN, total levels of cholesterol, obesity

• PAD affects blacks more; non-Hispanic blacks highest PAD risk factor

Inspect and Palpate the Arms

• Lift the person’s hands in your hands

  • Inspect hands, including turgor of skin, clubbing, and lesions

    • Detect early clubbing

  • Capillary refill

  • Radial pulse: grade amplitude on a 3 point scale

    • 3+

    • 2+

    • 1+

    • 0

Inspect and Palpate the Legs

• Palpate lower extremity pulses using bilateral comparison

Pretibial Edema and Pitting Edema

• Check pretibial edema

  • Depress skin over tibia or medial malleolus for 5 sec and release

  • Pitting edema scale

    • 1+ Mild pitting, slight indentation, no perceptible swelling

    • 2+ Moderate pitting, indentation subsides rapidly

    • 3+ Deep pitting, indentation remains, leg looks swollen

    • 4+ Very deep pitting, indentation lasts long time, leg grossly swollen and distorted

  • Use tape measure for more objective data

Pregnant Woman and Aging Adult

• Pregnant woman

  • Expect diffuse bilateral pitting edema in the lower extremities especially at the end of the day

  • Common findings third trimester

    • Peripheral pitting edema

    • Varicose veins

• Older adult

  • Trophic changes associated with arterial insufficiency may be seen

    • Thin, shiny skin

    • Thick, ridged nails

    • Loss of hair on lower legs